A HIGH PRICE paid

At about 90 per cent of the private clinics in Thailand, medical professionals are selling medicines without labels, affecting patients’ health, according to research by Si Sa Ket pharmacist Denchai Dokpong and a nationwide network of his colleagues. 

In late September 2014, Patcharin Vikistet, who operates a family resort near Chanthaburi, experienced this first-hand.

Four days after a Thai massage gone wrong, she visited a private practitioner in Chanthaburi to treat her back pain. After the medic diagnosed muscle inflammation, his wife, an anaesthesiologist, dispensed to Patcharin four packets of drugs – blue tablets, white capsules, yellow capsules, and brown and pink ones – costing her Bt420 and, later, her health.

Though she asked for labels, she was offered only written instructions for usage.

After taking the pills the following day, Patcharin says she suffered an excruciating headache. By evening, “I thought the drugs had burst a blood vessel in my brain,” she said.

“I thought maybe I would die.”

Around midnight, Patcharin began vomiting. At that point, the woman in her 50s, who had never visited a private clinic before, felt there was something wrong with the pills and decided to stop taking them.

A few days later, after a second failed attempt to acquire the medicines’ names, Patcharin discovered at a Bangkok hospital that her blood pressure was 170/90, bordering the level at which emergency care is needed. The high blood pressure and extreme headaches lasted until October 6.

She wants her story exposed in the media since she feels it will be more beneficial than filing a complaint to the Medical Council of Thailand.

Just days before Patcharin’s pain subsided, an 80-year-old man from Selaphum in Roi Et province was admitted to hospital in Muang Khon Kaen after taking unlabelled drugs that caused his International Normalised Ratio (INR) levels to soar to 5.4, above the average 2-3 for someone on Warfarin. 

The INR is a test that measures how long it takes for blood to clot. The higher the number, the higher one’s chance of losing a dangerous amount of blood through a cut or contusion. 

The man, who has a heart condition and asked to remain anonymous, had been visiting the hospital for his monthly check-up. A pharmacist there was unable to identify the five drugs his regular physician had prescribed him in Ban Phai, Khon Kaen, three days before for leg pain. Eventually it was concluded that three of the drugs were non-steroidal anti-inflammatory drugs (NSAIDs), which the pharmacist said had interacted with the Warfarin and caused the spike.

The man was admitted to the hospital for four days.

He has decided not to file a complaint against the doctor who prescribed him the medicines.

 

Getting away

While it is certainly illegal for an anaesthesiologist to dispense drugs at a private clinic, doctors prescribing and selling drugs without a label to patients is a legal grey area.

Holding doctors accountable for doing so is thus a confusing process, inhibiting consumers from speaking out against the practice, says Niyada Kiatying-Angsulee, manager of Thai Drug Watch, an NGO that advocates for safe drugs.

Since doctors are licensed to prescribe and sell medicines to patients by the Medical Council of Thailand, not by the Thai Food and Drug Administration, they are exempt from the requirement to label them under Section 26 of the Drug Act. That is, as long as they are purchased in Thailand, since Section 12 requires those who import medicines into the country to have a licence.

Meanwhile, though the Consumer Protection Act guarantees consumers “the right to receive correct and sufficient information and description as to the quality of goods or services [they receive]”, it doesn’t directly bind doctors to label medicines. 

And while Section 9 of the Declaration of Patient’s Rights – approved by the medical professions in Thailand – affords patients the right to “know or demand full and current information about their medical treatment”, the information obtained “must not infringe upon other individual’s rights”. 

Moreover, it isn’t law. 

But for consumers, this legal maze isn’t the only factor preventing them from holding medical professionals accountable over unlabelled drugs.

Filing a complaint may risk upsetting the social hierarchy or being considered impolite or untrusting of the doctor, says Komatra Cheungsatiansup, director of the Society and Health Institute at the Public Health Ministry. “This power has long been established because ... doctors ... can save your life, or even make it worse.”

Private clinics are also often the only option for many patients, who can’t afford to take time off during the day to visit a regular hospital or medical facility. 

The Consumer Protection Board’s complaint-filing system also doesn’t cater to everyone, as a complaint can only be made online, via fax or at its office in Bangkok. 

 

Determining the damage 

Tik Supavadee, who has been practising pharmacy in Selaphum for 14 years, says patchy public knowledge about medicines, particularly in rural communities, means that many people don’t realise that drugs can harm as well as help. That also makes the scale of the damage difficult to determine, Tik adds. And because not all drugs take immediate affect, consumers often aren’t able to link them with adverse affects so do not report the issue. 

It’s a “serious problem,” said Niyada. “If a consumer has adverse effects, how does the consumer tell another doctor what the name of the product is? It’s not consumer protection at all.”

She adds that doctors are selling medicines unlabelled so that they can charge patients more than they’d pay for them elsewhere. 

At private clinics, doctors often combine the cost of the consultation and the medicines prescribed into one bill, giving them the power to decide the figure. 

The rewards of doing so can be measured in the typical monthly salary of between Bt100,000 and Bt500,000 that doctors at private clinics earn, compared to the peak Bt50,000 per month that doctors at rural government health facilities can expect to take home, says Somsak Lolehka, president of the Medical Council of Thailand.

“Drugs are not Smarties; they have side effects,” explained Kathleen Holloway, World Health Organisation adviser in Essential Drugs and other Medicines for Southeast Asia. “If you don’t have a label and you don’t know [what you’re taking,] it’s a very dangerous practice,” she said.

Holloway points out that taking eight 500mg tablets of Paracetamol in 24 hours can cause death.

The problem is exacerbated in Thailand by the fact that neither the current Drug Act nor the two new ones pending since autumn 2014 prohibit doctors from selling unlabelled medicines to patients. 

Some of these drugs are also not registered with the FDA, says Chongmas Nitisingkarin, president of the Community Pharmacy Association of Thailand, who along with a nationwide team of pharmacists has been investigating private clinics over the past 21 years. 

Without labels and registration, there is no way of knowing the expiry date of medicines, or removing them from the market, says Holloway.

“This is the reason we have drug regulation authorities. ... It’s not safe at all. It doesn’t allow patients to have control over their medicines.”